How to Report Your Clinic for Healthcare Fraud

September 13, 2023

In the realm of healthcare, the United States government allocates significant taxpayer funds for programs like Medicare and Medicaid, and thus the responsibility of clinics, companies, and individuals to comply with the law and submit accurate reimbursement requests is of utmost importance. However, an alarming trend of submitting false or fraudulent claims has surfaced, resulting in the loss of billions of taxpayer dollars annually and consequently jeopardizing patient safety. This dire situation brings us to questions about how to recognize and report healthcare fraud, which has spurred the emergence of healthcare fraud attorneys who assist in reporting healthcare fraud and valiant qui tam relators who blow the whistle on wrongdoings.

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Understanding Healthcare Fraud and Kickbacks

At the heart of this issue is greed and actions taken consistent with greed that chip away at the honesty of the healthcare system. One of these wrongful actions, known as a “kickback in healthcare,” involves the sneaky exchange of rewards for sending patients or making certain purchases. Imagine this as someone obtaining a secret incentive for sending you to a specific doctor or buying a particular medicine, would you trust that they are doing it for your best interest or for the incentive?

Kickbacks mess up the quality of care patients receive, by first destroying the perspective of impartiality and sometimes in turn actually killing that impartiality. If a doctor is paid a certain kickback to prescribe a certain medicine versus then there’s a perception that he or she is steering you towards that medicine for the purpose of that reward and it’s hard to overcome that perception, even if the doctor is only putting the patient on it for their best interest. In the more egregious and slippery slope paradigm, the doctor may internally reconcile that the incentivized product is the better one because it aligns with their own economic interests and thus lose their objectivity about the product. Kickbacks can be reported and addressed through the False Claims Act and via the Anti-Kickback Statute (AKS) with different avenues for reporting, some of which if done promptly and properly could trigger a whistleblower reward.

Recognizing Healthcare Fraud

Healthcare fraud comes in various forms in addition to and separate from kickbacks. Healthcare providers try to game the system to recover monies they’re not entitled to. One scam is called “upcoding,” where the seriousness of a patient’s condition is exaggerated just to code at a higher level of reimbursement. Or the time spent with an encounter is exaggerated. Sometimes these are routinely done or reflexively billed, where they get more money back. In 2012, the Office of Inspector General (OIG) reported an estimate that coders incorrectly reported 3 percent of 5,941 present on admission indicators, which has resulted in at least one incorrect indicator on each of the claims upcoded. This may be just attributable to error unless there’s a discernable pattern. For example, here is the Medicare reimbursement schedule for patient encounters:

Visit level New patient code New patient time Established patient code Established patient time
Level 2 99202 15-29 99212 10-19
Level 3 99203 30-44 99213 20-29
Level 4 99204 45-59 99214 30-39
Level 5 99205 60-74 99215 40-54

If the staff is instructed to bill at a Level 4 reimbursement regardless of the actual time spent with the encounter (unless it’s more when they would bill more) it is a reflexive upcoding situation. That is, since Level 4 provides a higher level or reimbursement than level 2 and since no one is watching the clock, they may think they can get away with the scheme. More common is to upcode just one level. With Covid there were all sorts of schemes, one of which was to document symptoms when they were known for a higher level of reimbursement.

Another trick is “unbundling,” where services that should be grouped and billed together as one bundle are artificially separated, leading to higher charges. Imagine ordering a meal deal at a restaurant, but then being charged for each part separately.

The Role of Healthcare Whistleblowers

In the complicated world of healthcare, there are everyday heroes who double down on doing something really important, first they help their patients and then they help stop fraud. These are healthcare whistleblowers, and they play a big role in stopping bad things from happening. They expose dishonest things in their workplaces to help hold the company accountable and save the taxpayers money and sometimes help address patient health issues.
Different Ways to Report Healthcare Fraud

  1. Telling Someone at Work: A Tricky Choice- NOT RECOMMENDED

    Consider what would happen if you discovered unethical behavior in your healthcare clinic. You might want to inform someone, such as your boss or a special phone line, about it. But it’s not easy; you must decide if it’s safe, and you must understand the rules at your clinic. From our experience, availing yourself of an internal reporting mechanism often results in trouble for the reporting person who then defensively reaches out for a healthcare whistleblower lawyer since the company views them as part of the problem or looks to blame them for the conduct that they are nobly reporting.

  2. Telling the Government: Letting Them Know

    Another option is to notify the government. You can do this online or by phone. If you believe there is a problem with Medicare or Medicaid funds.
    But it is important to note that if you go directly to the government, you may not be eligible for a whistleblower award. We have seen many cases where whistleblowers will contact law firms later in the process after learning that they will not receive a whistleblower award, especially after reading that the government settled with the health care provider for many millions.

  3. Choosing a Whistleblower Law Firm

    The best and safest thing to do is to contact a whistleblower law firm that is experienced in handling such cases and learn about your rights. When we have plumbing problems, we call plumbers. We call roofers when we have problems with our roof. Similarly, we have whistleblower law firms in the healthcare fraud industry who can advise you on the best course of action.
    Under the False Claims Act, whistleblowers can receive up to 30% of what the government recovers, but the facts of the case must be presented in such a way that the government will investigate further. Because they receive so many complaints, they will prioritize the ones that appear promising. Also, if the qui tam lawsuit is not filed in the right way it is over before it begins.

Choosing the Best Whistleblower Law Firm

Some of the Best Whistleblower Law Firms have a team of lawyers working for you. Look for a firm that has a track record of success in handling qui tam cases from start to finish, like Brown, LLC and also has members that were former Department of Justice or FBI lawyers as they can seamlessly interface with the prosecuting agency. Also, it’s important that the False Claims Act lawyers articulate about the case and explain how they can assist you. Most accomplished whistleblower law firms will take cases purely on a contingency basis, meaning they’re only paid if they win and offer free, confidential consultations.